UPDATES IN CLINICAL TRIALS FOR HEMATOLOGICAL DISEASES

AJH Educational Material A JH

2015 Clinical trials update in sickle cell anemia
Natasha Archer,1 Fr!ed!eric Galacteros,2 and Carlo Brugnara3*

Polymerization of HbS and cell sickling are the prime pathophysiological events in sickle cell disease (SCD).
Over the last 30 years, a substantial understanding at the molecular level has been acquired on how a
single amino acid change in the structure of the beta chain of hemoglobin leads to the explosive growth of
the HbS polymer and the associated changes in red cell morphology. O2 tension and intracellular HbS
concentration are the primary molecular drivers of this process, and are obvious targets for developing new
therapies. However, polymerization and sickling are driving a complex network of associated cellular
changes inside and outside of the erythrocyte, which become essential components of the inflammatory
vasculopathy and result in a large range of potential acute and chronic organ damages. In these areas, a
multitude of new targets for therapeutic developments have emerged, with several ongoing or planned new
therapeutic interventions. This review outlines the key points of SCD pathophysiology as they relate to the
development of new therapies, both at the pre-clinical and clinical levels.
Am. J. Hematol. 90:934950, 2015. V
C 2015 Wiley Periodicals, Inc.

! Clinical Presentation and Pathophysiology of Sickle Cell Disease

The clinical phenotype of patients with sickle cell disease (SCD) can be exceptionally diverse, despite a finite number of mutations. Clinical mani-
festations range from almost no symptoms to multiple, potentially fatal, events. Ballas et al. divided the complications secondary to SCD according
to three main categories including hematological, pain, and complications affecting major organs, in order to more effectively standardize their
definition [1]. While management guidelines are available [2,3], not every SCD patient can be treated exactly the same way given each patients
individual manifestations of disease and variable response to therapies.
The most common acute manifestations of the disease include vaso-occlusive crisis (VOC), acute chest syndrome, stroke, priapism, sudden
deafness, and acute anemia, particularly from aplastic crisis and splenic sequestration. Individuals with SCD are also more susceptible to stroke
and serious bacterial infections. The spectrum of clinical manifestations is age dependent; women with SCD are particularly at risk during preg-
nancy. In addition to hemolytic anemia, common chronic complications affect major organs, such as brain, kidney, heart, lung, skin, retina,
vestibular-cochlear systems, and bone. Some of these complications are seen predominantly in adults. Iatrogenic complications should also be con-
sidered, such as delayed hemolytic transfusion reactions and impotence due to inadequate treatment of priapism. Over their lifetime, patients dif-
ferentially accumulate a wide spectrum of functional defects, which are either passive sequelae of the disease or further reinforce disease
pathophysiology and worsen its clinical manifestations, such as renal tubular dysfunctions, which facilitate the development of acidosis.
Acute manifestations of the disease are managed by treating the associated symptoms. In the acute setting, pain crises are treated with hydra-
tion, warm packs, and analgesics ranging from nonsteroidal anti-inflammatory drugs (NSAIDs) to opioids. Acute chest syndrome, which typically
manifests with respiratory symptoms ranging from an increased respiratory rate to desaturations, is treated with efforts to increase oxygen carrying
capacity, i.e. supplemental oxygen, incentive spirometry, and exchange blood transfusion. If pain is associated with acute chest syndrome, analge-
sics are provided to remove the associated reduction in ventilation. In splenic sequestration, severe, acute anemia is a life-threatening symptom,
and is thus treated with top-up blood transfusion. Stroke and serious bacterial infections are treated as they would be in non-SCD but the hemor-
rhagic risks associated with therapy should be carefully evaluated and glucocorticoids should be used with caution. In addition, SCD patients with
stroke receive either simple or exchange transfusions depending on their hemoglobin level and capacity to rapidly achieve a reduction to less than
30% for the remaining SS RBC measured by % HbS after transfusion.
Chronic manifestations sometimes need to be managed symptomatically, but are preferably managed prophylactically in an effort to decrease
morbidity associated with each condition. This often requires nonspecific treatment, but treatments that aim at decreasing the pathophysiology
associated with SCD, i.e. hemolysis and vaso-occlusion, are particularly needed. The complex clinical nature and evolving pathophysiology of SCD
emphasizes the need for very well coordinated follow-up and transition from childhood to adult care.
Preventative measures are currently the hallmark of the management of both acute and chronic manifestations of SCD. Even before disease
confirmation, after an initiation newborn screen returns positive for SCD, infants are started on penicillin prophylaxis. The meningococcal

1
Pediatric Hematology/Oncology Dana-Farber/Childrens Hospital Blood Disorders and Cancer Center, Boston, Massachusetts; 2Centre De R!ef!erence Des Syndromes
opital Henri-Mondor, APHP, UPEC, Creteil, France; 3Department of Laboratory Medicine, Boston Childrens Hospital, Harvard Medical
Dr!epanocytaires Majeurs, H^
School Boston, Massachusetts
Conflict of interest: All authors have no conflicts of interest to disclose
*Correspondence to: Carlo Brugnara, Department of Laboratory Medicine, Boston Childrens Hospital, 300 Longwood Avenue, Bader 760 Boston, MA 02115.
E-mail: carlo.brugnara@childrens.harvard.edu
Contract grant sponsor: NIH Training Grants (to N.A.); Contract grant numbers: 5T32HL007574 and 5K12HL087164-09.
Contract grant sponsor: Doris Duke Charitable Foundation; Contract grant number: 2013010.
Received for publication: 8 July 2015; Accepted: 8 July 2015
Am. J. Hematol. 90:934950, 2015.
Published online: 15 July 2015 in Wiley Online Library (wileyonlinelibrary.com).
DOI: 10.1002/ajh.24116

C 2015 Wiley Periodicals, Inc.

V

934 American Journal of Hematology, Vol. 90, No. 10, October 2015 doi:10.1002/ajh.24116
UPDATES IN CLINICAL TRIALS FOR HEMATOLOGICAL DISEASES
conjugate vaccine (MCV4) and pneumococcal polysaccharide vaccine
(PPV23), in addition to routine childhood immunizations, are given
to all children with SCD for added protection against encapsulated
bacteria. These interventions are meant to prevent illness and/or
death secondary to severe bacterial infections in the setting of func-
tional asplenia. Another example of prophylaxis is the use of chronic
transfusion, and now possibly hydroxyurea, for stroke prevention. Up
until recently, children with SCD and elevated Transcranial Doppler
(TCD) blood velocities were encouraged to begin a chronic transfu-
sion regimen in efforts to reduce the % HbS containing RBC thus
lessening vascular complications. In patients with known stroke or
silent cerebral infarcts, chronic transfusions have been shown to result
not only in a significant risk reduction of infarct recurrence, but also
improved quality of life [4]. However, chronic, monthly blood trans-
fusions are not without potential sequelae, most notably iron over-
load. The TWiTCH study set out to determine if daily hydroxyurea
could lower TCD velocity in children with SCD in a similar way as
blood transfusion. This trial was terminated early in November 2014
because hydroxyurea was determined to be noninferior to transfusion
therapy in reducing TCD blood velocity. Publication of these data
will be an important contribution to the ongoing discussions concern-
ing whether or not hydroxyurea can provide an alternative to chronic
blood transfusion for children at risk of developing stroke [5].
The only curative option currently available for SCD is hematopoi-
etic stem cell transplant (HSCT). This approach is mature enough to
have resulted in practice guidelines regarding its indications and
management [6,7]. However, the protocols currently in use are
numerous and the numbers of treated patients in each of the proto-
cols are limited. When one considers the substantial reduction in
mortality achieved with noncellular therapies over the last 20 years,
long-term mortality for older HSC-based therapies is similar to that
of optimal medical care. In addition, long-term complications of HSC
therapies are not well documented; the increased long-term risk of
solid tumors in transplanted SS patients is an area of particular
concern.
! Major Therapeutic Strategies for
Sickle Cell Disease
HbS polymerization and erythrocyte sickling
Seminal work by the NIH group of Eaton and coworkers has eluci-
dated the interplay of O2 tension and HbS concentration in the
kinetics of HbS polymerization [811] (Tables IIV). The extreme
dependence of the delay time for HbS polymerization on HbS con-
centration is a fundamental characteristic underlying SCD pathophys-
iology. It explains the very low clinical expression in sickle cell trait,
the presence of disease in HbSC compound heterozygosity, the bene-
ficial effects of increasing concentrations of HbF, and the modifica-
tions in disease severity when the cellular concentration of HbS is
decreased by concomitant alpha or beta thalassemia or iron deficiency
[18]. Four major avenues of potential therapies directly or indirectly
target HbS polymerization, with the final objective of decreasing poly-
merization and sickling.
Increasing intracellular concentration of HbF. An increasing frac-
tion of HbF inside the sickle erythrocyte is profoundly relevant not
only for the concomitant decrease in HbS, but also for the unique
capability of HbF to inhibit HbS polymerization. Large studies like
the Cooperative Study of Sickle Cell Disease have shown that HbF is
among the most important disease modifiers [19,20]. Similarly, stud-
ies on a variety of patient cohorts outside of the U.S. have shown
lower disease severity in the presence of higher values of HbF. In a
study involving Saudi and African American sickle cell patients,
despite similar hemoglobin beta (HBB) gene cluster haplotypes, dif-
doi:10.1002/ajh.24116
Clinical Trials in Sickle Cell Anemia
ferent clinical phenotypes in the Saudi cohort were attributed to their
higher values of HbF [21]. Effects of several HbF modifiers have been
described on both HbF values and other hematological parameters
[2125].
Studies by Platt et al., Charache et al., and others have led to the
approval of hydroxyurea as a therapeutic agent in adult patients
[26,27]. Early studies of 5-azacytidine and hydroxyurea treatment in
SCD patients were notable for an increase in F reticulocytes and HbF
elevation. This often led to an increase in hemoglobin despite mild
bone marrow suppression noted in other cell lines. More than a dec-
ade later, clinical benefits were demonstrated including a reduction in
pain crises and an associated reduction in mortality with increasing
number of cumulative years on hydroxyurea therapy [27,28].
While hydroxyurea has not yet been approved by the FDA for use
in children with SCD, several studies and its more aggressive inclu-
sion in the most recent SCD management recommendations speak to
its safety and effectiveness in a pediatric population [2,29]. In the
phase 1/2 HUG-KIDS trial, 52 children were treated at Maximum
Tolerated Dose (MTD) for 1 year, with no significant clinical adverse
effects; hematologic toxicities were found to be mild and reversible
[30]. In the Baby Hug phase 3 clinical trial, SCD infants 9 to 18
months of age treated with hydroxyurea and compared with a pla-
cebo, had reduced pain scores and fewer pain crises and acute chest
syndrome [31,32]. Importantly, hydroxyurea was not associated with
an increased risk of serious bacterial infections. Subsequent studies
have also shown no short-term effect of hydroxyurea on growth and
some positive effects on renal function [3335]. With this supportive
evidence, the most recent SCD management guidelines recommend
the use of hydroxyurea in both adults with three or more VOCs in
any 12-month period and, regardless of symptoms, in children greater
than 9 months of age diagnosed with sickle cell anemia [2,29].
Despite the overwhelming evidence supporting the clinical benefits of
hydroxyurea, only one out of four adult patients and possibly even
fewer are treated with this drug [36]. Extending hydroxyurea therapy
to all eligible patients should be a major target for all therapeutic
interventions for SCD. Hydroxurea is also being tested in a Phase 2
study in adult and pediatric patients with Hb SC disease (SCYTHE,
NCT02336373). Change in quality of life after 6 months at MTD is
the primary endpoint of this study. In adults, phlebotomy is allowed
if quality of life does not improve after 6 months at MTD.
The overall success of hydroxyurea has led to efforts exploring its
potential synergy with other drugs such as magnesium [37]. A study
investigating adjuvant magnesium pidolate in patients with HbSC dis-
ease treated with hydroxyurea was unfortunately closed early due to
slow enrollment; no difference in the primary outcome of hyperdense
cells or the secondary outcome of clinical events were observed across
the four treatments arms (HU 1 Mg, HU 1 placebo, Mg 1 placebo
and placebo 1 placebo) [38]. In vitro studies have provided evidence
that hydroxyurea reduces the endothelial expression of adhesive
ligands like Vascular Cell Adhesion Molecule-1 (VCAM-1) and the
activation of Lutheran/basal cell-adhesion molecule (Lu/BCAM)
[39,40]. Montelukast is a leukotriene receptor antagonist currently
approved for prophylaxis and chronic treatment of asthma. In vitro
data suggest that it inhibits eosinophil adhesion to VCAM-1 [41]. An
ongoing trial is investigating whether the addition of montelukast ver-
sus placebo to hydroxyurea leads to a measurable reduction in soluble
VCAM-1 (Vanderbilt University, NCT01960413).
NHLBI is currently conducting a trial in 24 patients, age 15 and
older, to test a new dosing algorithm to maximize response and
reduce side effects of hydroxyurea (NCT02225132, Primary outcome:
Maximal HbF values). Baylor College of Medicine is testing a new
approach to shorten the time required to achieve MTD for hydrox-
yurea (NCT02042222, up to 105 patients, age 116 years.). It is how-
ever not clear how adherence to treatment can be eventually
American Journal of Hematology, Vol. 90, No. 10, October 2015 935
Archer et al. UPDATES IN CLINICAL TRIALS FOR HEMATOLOGICAL DISEASES

TABLE I. Planned, ongoing or recently completed Phase 1 trials

Company Drug Mechanism Indication Route Clintrials.gov Status

HB F-Anti-sickling
The Cleveland Decitabine HbF induction Prophylaxis Oral NCT01685515 Open
Clinic (Dacogen) and HbSS, HbSb0, HbSb1, ASH 2014 # 90
tetrahydrouridine HbSC
!18 years
Celgene Pomalidomide HbF induction Prophylaxis Oral NCT01522547 Completed
(Pomalyst) HbSS, HbSb0
18 years > 60 years
Novartis Panobinostat HbF induction Prophylaxis Oral NCT01245179 Open
Pharmaceuticals (Farydak) (HDAC inhibition) HbSS, HbSb0
!18 years
AesRx (Baxter 5-hydromethyl-2- Increased O2 Prophylaxis Oral NCT01597401 Completed
International) furfural (AES-103) affinity HbSS
18 years ! 65 years
Prolong PEGylated O2 and CO delivery Prophylaxis IV NCT01847222 Completed;
Pharmaceuticals carboxyhemoglobin (oxygenation and Healthy ASH 2014 #1372
bovine (Sanguinate) anti-inflammation) 18 years ! 45 years
Prolong PEGylated carboxyhe- O2 and CO delivery Prophylaxis IV NCT01374165 Recruitment
Pharmaceuticals moglobin bovine (oxygenation and HbSS, HbSb0, HbSb1, suspended
(Sanguinate) anti-inflammation) HbSC
18 years ! 65 years
Prolong PEGylated carboxyhe- O2 and CO delivery Prophylaxis IV NCT01848925 Completed
Pharmaceuticals moglobin bovine (oxygenation and HbSS
(Sanguinate) anti-inflammation) !18 years
Invenux, LLC SCD-101 Inhibition of sickling Prophylaxis Oral NCT02380079 Open
HbSS, HbSb0
18 years ! 55 years
Global Blood GBT440 (formerly Increased O2 Prophylaxis Oral NCT02285088 Open;
Therapeutics GTx011) affinity Healthy, 18 years ! 55 ASH 2014 # 217
years (mouse) and
HbSS, 18 years ! 60 #1370 (in vitro)
years
Anti-inflammatory
NKT Therapeutics NKTT120 Anti-inflammation Prophylaxis IV NCT01783691 Completed;
HbSS, HbSb0 ASH 2014 #2718
18 years ! 60 years
Childrens Hospital Zileuton (ZYFLO) Anti-inflammation Prophylaxis Oral NCT01136941 Completed; [12]
Medical Center HbSS, HbSb0, HbSb1,
HbSC
!12 years
NHLBI Regadenoson Anti-inflammation VOC diagnosis IV NCT01566890 Completed; [13]
(Lexiscan) HbSS, HbSb0
18 years ! 70 years
Pfizer PF-04447943 Phosphodiesterase Prophylaxis Oral NCT02114203 Open
9 inhibitor HbSS, HbSb0
18 years ! 70 years
Vanderbilt Budenoside Anti-inflammation Post-ACS prophylaxis Inhaled NCT02187445 Open
University HbSS, HbSb0
1 years > 4 years
Anti-adhesion
University of Miami Propranolol Anti-adhesion Prophylaxis Oral NCT02012777 Open
and Duke HbSS, HbSb0
University 7 years ! 17 years
University of Miami Propranolol Anti-adhesion Prophylaxis Oral NCT01077921 Completed
and Duke HbSS, HbSb0
University !18 years
Albert Einstein Col- Immune Globulin Anti-adhesion Acute VOC treatment IV NCT01757418 Completed; [106]
lege of Medicine (Gamunex-C) HbSS, HbSb0, HbSb1
12 years ! 65 years
University Hospitals Sodium bicarbonate Alkali therapy Low serum bicarbonate Oral NCT01894594 Open
Case Medical levels treatment
Center HbSS
!18 years
Other
Sangart MP4CO (pegylated car- Anti-sickling and Prophylaxis IV NCT01356485 Completed
boxyhemoglobin, vascular stasis HbSS, HbSb0 Phase Ib
> 90% CO-Hb !18 years Discontinued
saturation)
NHLBI Topical sodium nitrite Increased blood Leg ulcers treatment Topical NCT01316796 Completed;
cream flow HbSS, HbSb0, HbSb1, [14]
HbSC
!18 years

936 American Journal of Hematology, Vol. 90, No. 10, October 2015 doi:10.1002/ajh.24116
UPDATES IN CLINICAL TRIALS FOR HEMATOLOGICAL DISEASES Clinical Trials in Sickle Cell Anemia

TABLE II. Planned, ongoing or recently completed Phase 2 trials

Funding Drug/Company Mechanism Indication Route Clintrials.gov Status

HB F-Anti-sickling
NHLBI Decitabine HbF induction Prophylaxis IV NCT01375608 Open
HbSS, HbSb0, HbSC
!18 years
Hema-Quest 2,2-dimethylbutyrate HbF induction Prophylaxis Oral NCT01601340 Completed; [15]
Pharmaceuticals (HQK-1001) HbSS, HbSb0
12 years ! 60 years
Baxter International 5-hydromethyl-2-furfu- Increased O2 Prophylaxis Oral NCT01987908 Open
Inc. ral (AES-103) affinity HbSS
18 years ! 60 years
Dana Farber Cancer Vorinostat (Zolinza) HbF induction Prophylaxis Oral NCT01000155 Discontinued
institute HbSS, HbSb0
!18 years
Prolong PEGylated carboxyhe- O2 and CO delivery Acute VOC treatment IV NCT02411708 Not yet open
Pharmaceuticals moglobin bovine (oxygenation and HbSS, HbSb0, HbSb1,
(Sanguinate) anti-inflammation) HbSC
!12 years
Baylor College of Hydroxyurea HbF induction; Prophylaxis Oral NCT02336373 Open
Medicine Rheological HbSC (SCYTHE)
improvement 5 years ! 21 years
Baylor College of Hydroxyurea 6 HbF induction; Prophylaxis Oral N/A Not yet open
Medicine Phlebotomy Rheological HbSC
improvement 18 years ! 69 years
Anti-adhesion, hemolysis
Novartis (Selexys) SelG1 Anti-P-selectin Prophylaxis IV NCT01895361 Open
HbSS, HbSb0, HbSb1, (SUSTAIN)
HbSC
16 years ! 65 years
Vanderbilt Montelukast (Singulair) Anti-adhesion Prophylaxis Oral NCT01960413 Open
University HbSS, HbSb0
16 years ! 60 years
St. Louis University Abciximab (ReoPro) Anti-adhesion Acute VOC treatment IV NCT01932554 Discontinued
HbSS, HbSb0, HbSC
5 years ! 25 years
Astra Zeneca Ticagrelor (Brilinta) PLT aggregation Prophylaxis Oral NCT02214121 Open
inhibition HbSS, HbSb0
2 years ! 18 years
University of North Rivaroxaban (Xarelto) Anticoagulant Prophylaxis Oral NCT02072668 Open by
Carolina HbSS, HbSb0 invitation only
18 years ! 55 years
Dilaforette AB (Swe- Sevuparin Anticoagulant Acute VOC treatment IV N/A Study design
den) Ergomed plc phase
(UH)
University of Unfractionated heparin Anticoagulant Acute Chest Syndrome IV NCT02098993 Open
Pittsburgh treatment
HbSS, HbSb0, HbSC
18 years ! 20 years
Boston Childrens Inhaled NO NO repletion Acute VOC treatment Inhaled NCT00142051 Discontinued
Hospital HbSS, HbSb0, HbSC
9 years ! 22 years
Wake Forest School Beet Juice NO repletion Prophylaxis Oral NCT02162225 Open
of Medicine (Unbeetable) HbSS, HbSb0
19 years ! 65 years
Bio Products Labo- BPL Haptoglobin Free Hb depletion Prophylaxis IV N/A EU Orphan drug
ratory (UK) designation
2011
University of North Eptifibatide (Integrilin) PLT aggregation Acute VOC treatment IV NCT00834899 Discontinued;
Carolina inhibition HbSS, HbSb0, HbSC [16]
18 years ! 55 years
Anti-inflammatory
NHLBI Regadenoson Anti-inflammation Acute VOC treatment IV NCT01788631 Open
(Lexiscan) HbSS, HbSb0
10 years ! 70 years
Childrens Hospital Simvastatin (Zocor) Anti-inflammation Prophylaxis Oral NCT01702246 Open
& Research HbSS, HbSb0
Center !10 years
University of North Atorvastatin (Lipitor) Anti-inflammation Prophylaxis Oral NCT01732718 Open by invita-
Carolina HbSS, HbSb0 tion only
18 years ! 60 years
Fish oil (Lovaza) Anti-inflammation Prophylaxis Oral NCT01202812 Unknown

doi:10.1002/ajh.24116 American Journal of Hematology, Vol. 90, No. 10, October 2015 937
Archer et al. UPDATES IN CLINICAL TRIALS FOR HEMATOLOGICAL DISEASES

TABLE II. Continued

Funding Drug/Company Mechanism Indication Route Clintrials.gov Status

0
Thomas Jefferson HbSS, HbSb
University, 10 years >19 years
Mount Sinai School Inhaled Mometasone Anti-inflammation Acute VOC treatment Inhaled NCT02061202 Open
of Medicine Furoate HbSS, HbSb0
!15 years
NKT Therapeutics NKTT120 Anti-inflammation Prophylaxis IV N/A Study design
phase
Boston University Macitentan (Opsumit) Endothelin blocker Pulmonary arterial hyper- Oral NCT02126943 Open
Medical Center tension treatment
Childrens Hospital Losartan (Cozaar) Reduction of intra- Sickle nephropathy pro- Oral NCT01479439 Open
Medical Center glomerular phylaxis and/or
pressure treatment
HbSS, HbSb0
!6 years
University of Ala- Losartan (Cozaar) Reduction of intra- Sickle nephropathy Oral NCT02373241 Open
bama at glomerular prophylaxis
Birmingham pressure HbSS, HbSb0
6 years ! 19 years
Lagos State Sorghum bicolor Anti-oxidant Prophylaxis Oral NCT01704794 Open
University (Jobelyn) HbSS
14 years ! 40 years

improved by the optimization of MTD for hydroxyurea. While HbF
is a widely used endpoint to assess both MTD and therapeutic effec-
tiveness, other endpoints such as the % of dense red blood cells are
relevant for disease pathophysiology, have shown value and could be
used to guide treatment [42,43].
Other compounds known to increase HbF are currently being
investigated clinically. Decitabine (5-aza-2-deoxycytidine), a drug
commonly used to treat myelodysplastic syndrome, inhibits DNA
methyltransferase. It is currently 4 years into a phase 2 clinical trial,
testing the safety and effectiveness of weekly to biweekly injections
administered over 1 year in SCD patients older than 18 years in
whom hydroxyurea was not deemed effective or tolerable
(NCT01375608, Table II). Oral Decitabine plus Tetrahydrouridine, a
cytidine deaminase inhibitor, is also being investigated in a similar
patient population and is currently in year 2 of its phase 1 clinical
trial. MTD, safety, and effect on HbF induction are being determined

TABLE III. Currently planned, ongoing, or recently completed Phase 3 trials

Company Drug Mechanism Indication Route Enrollment Clintrials.gov Status

Eli Lilly & Daiichi Prasugrel Platelet inhibition Prophylaxis Oral 240, NCT01794000 Open
Sankyo (Effient) HbSS, HbSb0
2 years ! 17 years
Emmaus Medical L-glutamine vs Anti-oxidant Prophylaxis Oral 230, NCT01179217 Completed;
placebo HbSS, HbSb0 ASH 2014 # 86
!5 years
MAST Therapeutics MST-188 Anti-adhesion Acute VOC IV 388, NCT01737814 Open
treatment HbSS, HbSb0, HbSb1, (EPIC)
HbSC
4 years ! 65 years
GlycoMimetics GM-1070 Anti-P-selectin Acute VOC IV 350, NCT02187003 Phase 2 completed;
(Rivipansel) treatment HbSS, HbSb0, HbSb1, [100]
HbSC
!6 years
BC Childrens Hos- MgSO4 Vasodilation? Pain Acute VOC IV 120 (98 enrolled), NCT00313963 Completed (MAST); [17]
pital and Univer- reduction? treatment HbSS, HbSb0, HbSb1,
sity of BC, HbSC
Vancouver 4 years ! 18 years
PECARN (Pediatric MgSO4 Vasodilation? Pain Acute VOC IV 208 NCT01197417 Completed (MAGIC);
Emergency Care reduction? treatment HbSS, HbSb0, HbSb1, ASH 2014 # 88
Applied Research HbSC
Network) 4 years ! 21 years
Academisch Med- N-Acetylcysteine Anti-oxidant Prophylaxis Oral 140, NCT01849016 Open
isch Centrum - HbSS, HbSb0, HbSb1,
Universiteit van HbSC
Amsterdam !12 years
Duke University Apixaban Anticoagulant Prophylaxis Oral 60, NCT02179177 Not yet open
Medical Center (Eliquis) HbSS, HbSb0, HbSC
18 years ! 80 years

938 American Journal of Hematology, Vol. 90, No. 10, October 2015 doi:10.1002/ajh.24116
UPDATES IN CLINICAL TRIALS FOR HEMATOLOGICAL DISEASES Clinical Trials in Sickle Cell Anemia

TABLE IV. Compounds in preclinical development

Indication/
Company Drug Mechanism Route Other Status

Acetylon HDAC 1=2 inhibition HbF induction ASH 2014 #335

Pharmaceuticals
EpimedX EdX-17 HbF induction (ferri- ASH 2014 #1357
tin heavy chain
activation)
Errant Gene Trichosic HbF induction Early stage of
Therapeutics development
Phoenicia Bioscien- PB-04 HbF induction Prophylaxis ASH 2014 #2687 for
ces & NCATS- other targets
TRND
Isis Antisense nucleotides HbF induction via ASH 2014 # 4038
Pharmaceuticals KLF1 reduction
NIH (academic, U RN-1 Inhibition of LSD1, a SC ASH 2014 #336 Baboon-study shows HbF
Chicago repressor of induction
gamma-globin
expression
Global Blood GTx011 Increase O2 affinity ORAL ASH 2014 #1370 Sickle mouse study ASH
Therapeutics 2014 # 217
Virginia Common- INN-270 and TD-7 Increase O2 affinity Sickle mouse study open
wealth And CHOP
Erytech Pharma Enhoxy O2 delivery EU Orphan drug designa-
tion 2012
Biogen Idec Tysabri (Natalizumab) Anti-adhesion IV ASH 2014 #221 Approved for relapsing
MS
Archemix ARC5690 Aptamer anti- IV In liquidation
adhesion
Biogen Idec TYSABRI, Natalizumab VLA4 blocker, anti- Treatment IV Approved for relapsing
adhesion MS & Crohns disease
Acceleron Pharma Luspatercept Ligand trap SC ASH 2014 #4055 Phase 2 in MDS and Beta-
(ACE-536) TGFbeta thalassemia intermedia
superfamily
ReveraGen VBP15 Anti-inflammation ORAL Studies in Duchenne
Biopharma (like predniso- muscular dystrophy
lone, NF-kB inhi-
bition, fewer side
effects)
Biogen Idec Tecfidera V
R (Dimethyl Anti-inflammation Prophylaxis Approved for relapsing
fumarate) ORAL MS
Addex Therapeutics TFNR1 NAM A2a PAM A2AR, Anti- ORAL Studies in Parkinsons
inflammation disease
Advinus PNQ103 AQ2BAR antagonist ORAL Ex-vivo studies on SCD
Therapeutics RBCs
Pfizer PF-04447943 Phosphodiesterase ORAL ASH 2014 #2694 Unsuccessful in Alzhei-
9 inhibitor mers trial. Reduced
vaso-occlusion in SS
mouse
Duke University TBD MEK1/2 and ERK1/2 [170]
inhibition
Alnylam ALN-TMP RNAi Tmprss6, to Iron overload SC Studies in Beta-
Pharmaceuticals reduce Fe load thalassemia

for Pomalidomide, a derivative of thalidomide that also inhibits
angiogenesis, in SCD patients greater than 18 years of age and who
are also hydroxyurea refractory or intolerant (Table I). A phase 2
clinical trial for 2,2-dimethylbutyrates (HQK-1001), an oral HbF
inducer, was recently terminated early for lack of effects [15,44]. Inhi-
bition of histone deacetylase (HDAC) is being investigated as a mech-
anism to increase HbF; Vorinostats phase 2 clinical trial was recently
closed due to the lack of measurable effects, while panobinostat
(LBH589) is still in phase 1.
Still in development are a handful of compounds that have some
promising preclinical data (Table IV). BCL11A is a transcriptional
suppressor of HbF production; a substantial component of HbF vari-
ability is associated with genetic polymorphisms in BCL11A [45,46].
Acetylons ACY-957, also a selective HDAC 1=2 inhibitor, is thought
to downregulate BCL11A, and upregulate GATA 2, which conversely
induces HbF (ASH 2014 #335). Pracinostat (SB939), another HDAC
inhibitor, and PB-04 also induced HbF production in erythroid pre-
cursors in SCD and beta thalassemic patients (ASH 2014, # 2687).
Ferritin heavy chain (FtH), a protein that stimulates gamma globin, is
activated by EdX-17, augmenting HbF levels in betaYac mice to
greater than 25% (ASH 2014, # 1357). Lysine Specific Demethylase-1
(LSD-1) inhibitor, RN-1, which has previously demonstrated a two to
threefold increase in F cells while inducing g-globin mRNA levels
five to eightfold in mice (ASH 2014, # 561) has also induced high
levels of HbF, F reticulocytes, and F cells in baboons (ASH 2014,
#336). Erythroid Kruppel like factor (KLF1), involved in -globin
induction and g-globin suppression, has also been targeted using
antisense oligonucleotides (ASOs) in both murine and human cell
lines. Subcutaneous administration of KLF1 ASOs in mice and rats
has been shown to reduce -globin production (ASH 2014, #4038).

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Archer et al.
Valproic acid and trichostatin have been shown to increase g-globin
gene expression in human liquid erythroid cultures [47]. Trichostatin
A (Errant Gene Therapeutics) is a histone deacetylase inhibitor,
which may induce HbF expression, but no data have been published
or presented so far. For many of the preclinical leads described above,
it should be noted that ability of inducing HbF production in vitro in
cell lines does not necessarily translate into in vivo efficacy in
humans. The limited availability of nonhuman primate models also
poses a significant challenge to the pre-clinical development of these
compounds.
Reducing intracellular concentration of HbS. This avenue com-
prises either modification of ion transport across the erythrocyte
membrane with the intent of preventing sickle cell dehydration or
reduction of HbS concentration by iron deficient erythropoiesis.
Given the unique dependence of the kinetics of HbS polymerization
on HbS concentration, the presence of erythrocyte dehydration in
SCD has important implications for pathophysiology and was origi-
nally and unsuccessfully targeted in 1980 in a study aimed to induce
red cell swelling with hypo-osmolarity [48]. Over the last 30 years,
the major pathways which are responsible for erythrocyte dehydration
have been characterized in substantial detail [49]. They include the
K-Cl cotransport (KCC1,3,4) [5054], the Ca-activated Gardos chan-
nel (KCCN4) [5559], and Psickle (most probably mediated by the
mechano-sensitive ion channel Piezo 1) [6062]. Pharmacological
inhibition of these pathways has been demonstrated in vitro and in
vivo in transgenic mouse models. Clinical trials with dietary magne-
sium supplementation (Mg-pidolate) in patients with SCD have
shown increases in red cell magnesium content, inhibition of K-Cl
cotransport, and improvements in erythrocyte hydration, but there
have been no completed controlled trials testing clinical efficacy of
this approach [63,64]. A phase 1 study of oral Mg-pidolate supple-
mentation established the MTD for children with SCD concomitantly
treated with hydroxyurea [36]. As discussed above, a study on oral
Mg pidolate supplementation in patients with SC disease was termi-
nated early due to poor enrollment, but the limited data collected
showed no changes in erythrocyte Mg or cell dehydration [37]. Clini-
cal studies on the inhibition of the Gardos channel were first con-
ducted in the acute settings with IV cetiedil [65] and subsequently
with oral clotrimazole and senicapoc as prophylactic agents. These
latter studies resulted in reduction of cell dehydration, improvement
of anemia, but no measurable improvements in the relevant clinical
endpoints, and an actual increase in painful crises in the subgroup of
patients not receiving hydroxyurea [6668]. Since Hb increased in all
senicapoc-treated patients, it is possible that the associated increase in
blood viscosity negated the benefit of reducing cellular HbS concen-
tration, and resulted in increased vaso-occlusion. However, there was
no correlation between Hb values or changes in Hb values and pain
rates in patients treated with senicapoc. In vitro and in vivo data
have shown a role for endothelin-1 (ET-1) receptor blockade in
reducing erythrocyte dehydration, most likely due to a functional
connection between activation of this receptor and activation of the
Gardos channel [69]. It remains to be determined if targeting ET-1
can achieve a greater reduction in cell dehydration than targeting the
Gardos channel itself.
Isolated reports of improvement in SCD due to concomitant hypo-
chromia induced by iron deficiency have so far not translated into
viable therapeutic strategies and have not considered potentially asso-
ciated reduction in HbF [70,241160071]].
Direct inhibition of HbS polymerization. In vivo chemical modifi-
cation of HbS resulting in inhibition of polymerization has been an
elusive therapeutic goal. Obvious challenges to this approach are the
high concentration of Hb in the erythrocyte requiring a substantial
amount of modifying compound to be absorbed by the GI tract and
to cross the erythrocyte membrane without affecting other crucial cel-
940 American Journal of Hematology, Vol. 90, No. 10, October 2015
UPDATES IN CLINICAL TRIALS FOR HEMATOLOGICAL DISEASES
lular functions. Several compounds have been tested, all with disap-
pointing results so far. Na cyanate mediates an irreversible
carbamylation of the aminoterminal valine of HbS which results in
reduced polymerization and sickling [72]. In vivo studies with extrac-
orporeal carbamylation showed measureable changes in several hema-
tological parameters [73], however, significant toxicities were
observed most likely due to carbamylation of other targets, resulting
in peripheral neuropathy, CNS toxicity, weight loss, and cataract for-
mation. BW12C, a substituted benzaldehyde, showed significant in
vivo modification of HbS when administered parenterally to patients
with SCD [74,75], but it was not further developed due to significant
toxicity observed with a related compound.
The food additive vanillin binds to HbS and reduces polymeriza-
tion and sickling by both an allosteric shifting of oxygen affinity and
a stereospecific inhibition of polymer assembly [76]. Reduced poly-
merization and sickling were reported following a double-blind, pla-
cebo-controlled in vivo study using 1 g vanillin/day for 40 days in 30
patients with SCD in Cuba [77]. However, no additional studies were
carried out with this compound. Recent evidence suggests that vanil-
lin may adversely affect red cell ion transport and produce K loss and
dehydration of sickle cells [78]. INN-270 and TD-7, two derivatives
of vanillin, demonstrate high rates of HbS binding and modification
resulting in a shift to a higher oxygen affinity hemoglobin state (ASH
2014, #218) [79]. Sickle mouse studies using these two compounds
are ongoing.
Indirect inhibition of HbS polymerization by increasing oxygen
affinity. Several compounds have been identified that indirectly
inhibit HbS polymerization by shifting the partial pressure of oxygen
at which 50% of hemoglobin is saturated with oxygen (P50). For
some of the compounds described in the preceding section, such as
BW12C, it is not completely understood how much of the antisick-
ling effect is due to inhibition of polymerization and how much to a
left-shift in P50. A general concern for this approach is that a reduc-
tion in tissue oxygen delivery may produce a compensatory increase
in hemoglobin, with concomitant increased viscosity and vaso-
occlusion [80]. Sudden interruption of this kind of treatment may
also expose patients to substantial complications due to the increased
overall mass of circulating sickle cells.
Even including some of the drugs discussed in the preceding section, a
limited number of clinical trials have been conducted so far. Oral admin-
istration of Tucaresol, a substituted benzaldehyde, resulted in measure-
able changes in oxygen affinity, but also in significant toxicity [81].
The active ingredient for AES-103 (Baxter International Inc.) is 5-
hydroxymethyl-2-furfural (5-HMF), which has been shown to form a
high-affinity Schiff-base adduct with HbS and indirectly inhibits sick-
ling via a leftward oxygen curve equilibrium shift (ASH 2014 # 2699)
[82]. In vitro 5-HMF reduces sickling-induced dehydration (Gardos
and Psickle) while it increases K loss and dehydration mediated by the
K-Cl cotransport [83]. A phase 1 clinical trial tested oral doses of
AES-103 up to 4,000 mg in 18 patients with SCD, some treated with
hydroxyurea, with no significant side effects [84]. AES-103 is cur-
rently being tested in a phase 2 clinical trial (Table II).
GBT440 (formerly GTx011, Global Blood Therapeutics, South San
Francisco, CA), increases HbS oxygen affinity and diminishes cell
sickling in vitro, while it prolongs red cell survival in vivo in sickle
(Townes) mice (ASH 2014 #217, # 1370). A phase 1/2 clinical trial is
ongoing to assess safety, pharmacokinetics and pharmacodynamics of
oral GBT440 (single and multiple doses, administered once daily) in
healthy subjects and in patients with SCD (Table I).
While reducing oxygen carrying capabilities, CO has multiple
potentially beneficial effects in SCD, which include inhibition of poly-
merization, increase in oxygen affinity, reduced inflammation, and
increase antioxidant responses. Delivery of CO via a pegylated hemo-
globin saturated with CO has improved vaso-occlusion in a mouse
doi:10.1002/ajh.24116
UPDATES IN CLINICAL TRIALS FOR HEMATOLOGICAL DISEASES
model of SCD [85]. It remains to be determined if this can be
achieved in humans without significant side effects.
The inflammatory vasculopathy of sickle cell disease
Adhesion of sickle cells to endothelium and vaso-occlusion. Adhe-
sion of sickle cells to endothelium plays a major role in SCD patho-
physiology, especially as it relates to sickle vaso-occlusion. It is
generally believed that vaso-occlusion develops from adhesion of
sticky sickle RBCs to endothelium, followed by trapping and poly-
merization of rigid, less deformable cells [86,87].
The mechanisms supporting the adhesion of sticky sickle erythro-
cytes to endothelium as well as additional, cooperative adhesive inter-
actions involving activated leukocytes, monocytes, and platelets are of
great interests, since interfering with these mechanisms has the poten-
tial to greatly impact clinical severity. As we learn more about the
specific receptors involved in the adhesion process, new therapeutic
targets are coming into play to prevent and/or reverse vaso-occlusion.
Selectins (P, E, and L) play a crucial role in adhesion of leukocytes
to endothelium [88]. In sickle erythrocytes, P-selection and E-selectin
have therefore been explored as potential targets. Considerable debate
has been generated regarding the single selective (P or E) versus pan-
selectin blockade. There are also concerns about the fact that selectins
mediate adhesion mostly in the presence of shear stress [89,90], and
it is not clear how much this mechanism is actively engaged when
the blood flow is reduced or stopped as presumably happens in VOC.
Matsui et al. demonstrated that the mechanism of decreased sickle
cell adhesion via unfractionated heparin is through P-selectin inhibi-
tion [91]. Unfractionated heparin was shown to bind to P- and L-
selectins and inhibit their function, while low molecular weight hepa-
rins did not [92]. Promising results in a small cohort of patients with
SCD were obtained with Pentosan Polysulfate Sodium (PPS), an agent
used for treatment of pain associated with interstitial cystitis
(Elmiron, Janssen Pharmaceuticals). PPS was shown to block P-
selection adhesive processes in vitro, to normalize microcirculatory
blood flow, and to reduce markers of vascular injury in vivo [93].
Availability of an orally-absorbed selectin inhibitor would be a major
advantage compared with those requiring SC injections. In 2007, a
randomized, double-blind trial in 253 patients with acute VOC
showed positive results on duration of crises, hospitalization and pain
intensity with the daily SC administration of 175 IU/Kg of Tinza-
parin, a LMWH [94]. US marketing of Tinzaparin, (Innohep, LEO
Pharma, Ballerup, Denmark) was discontinued in February 2011.
Sevuparin, a chemically modified heparin, currently being studied
as a antimalarial agent, has also been shown to reduce sickle red cell
and leukocyte adhesion in vitro, to stimulated endothelial cells [95].
Given promising in vivo studies in nude mice demonstrating
decreased vaso-occlusion following TNF-a exposure, Dilaforette AB
(Sweden) and Ergomed plc (UK) are planning a phase 2 study using
sevuparin as an acute therapy for VOCs (Table II). Hemostatic bal-
ance is of critical pathophysiological importance in SCD: hemorrhagic
(retinal, renal, brain) disease as well as thrombotic events (pulmonary
embolism, phlebitis) are not uncommon. Thus contrary to Tinza-
parin, LMWH agents like Sevuparin and pentosan that have limited
anticoagulation properties may provide a safer alternative.
GMI-1070 (Rivipansel, GlycoMimetics Inc.) is a E-selectin inhibitor
which was shown to be safe and to produce some positive biomarker
changes in a phase 1 study when injected IV in 15 SCD patients [96].
GMI-1070 was studied in phase 2 study with the primary outcome
measure being a reduction in time to resolution of VOC. No statisti-
cally significant effects were observed on the primary outcome mea-
sure, while plasma E-selectin (ASH # 2704), opioid and overall pain
medication usages were significantly reduced [97100]. Despite hav-
ing failed its primary outcome, GMI-1070 will be tested in a phase 3
doi:10.1002/ajh.24116
Clinical Trials in Sickle Cell Anemia
trial, on SCD patients 6 years of age and older hospitalized for pain
(Table III). The primary outcome of this study is time to readiness to
discharge, while secondary outcomes include amount and duration of
opioids and readmission rates. The initiation of this phase 3 trial has
been delayed due to manufacturing issues.
The SUSTAIN trial is a phase 2 multicenter trial currently assess-
ing whether SelG1 (Selexys Pharmaceuticals, Oklahoma City, OK and
Novartis Pharmaceuticals), a humanized monoclonal antibody to P-
selectin, is safe and effective when given IV to patients on or off
hydroxyurea (Table II). ARC5690, an anti-P-selectin aptamer, was
considered for preclinical development by Archemix, but this com-
pany is now in liquidation (Table IV) [101].
Almost 15 years ago, IV Poloxamer 188 (Flocor), purified surfac-
tant, was tested in a large phase 3 clinical trial to assess its efficacy in
reducing the duration of painful crises. A limited effect was seen in
children and subjects concomitantly treated with hydroxyurea [102].
A smaller study subsequently showed measurable improvement in
microcirculatory parameters during VOC [103]. A second phase 3
trial with this compound, now renamed MST-188 is currently under
way (Mast Therapeutics, San Diego, CA) to test its effectiveness in
shortening VOC in children and adults (Table III).
Very late antigen 4 (VLA-4) or a4b1 is a cell surface integrin that
mediates reticulocyte interactions with the endothelium, vascular
adhesion molecule 1 (VCAM1), and plasma fibrinogen. Natalizumab,
a recombinant humanized antibody currently approved for relapsing
multiple sclerosis (MS) and Crohns disease, binds to the a4 subunit
of VLA-4. Sickle cell reticulocyte and leukocyte adhesion to VCAM-1
was blocked in whole blood samples obtained from subjects with
SCD and saturated with Natalizumab at plasma trough concentrations
measured in MS and Crohns disease patients, (ASH 2014, #221).
RBC have beta adrenergic receptors that may, under adrenergic
stress, activate some adhesion molecules like RBC LU-BCAM, favor-
ing initiation of VOC as well as generating vasospasm. Propranolol, a
frequently used beta-blocker in children and adults, has been shown
to inhibit epinephrine upregulation of sickle RBC endothelial adhe-
sion in animal studies and in a phase 1 clinical study [104].
PF04447943 (PDE9i, Pfizer Inc.), an inhibitor of phosphodiesterase-
9A enzyme, was unsuccessfully tested in a Phase 2 trial in Alzheimers
disease [105]. This compound decreased adhesion in a SCD mouse
model (ASH 2014, # 2694). A phase 1 clinical trial is planned for
patients with SCD on or off hydroxyurea (Table I).
A phase 1 study in 15 patients with Hb SS or Hb Sbthal experi-
encing an acute painful crisis showed changes in neutrophil activa-
tion markers following a single infusion of intravenous
immunoglobulin (IVIG, from 100 to 800 mg/kg). Although not sig-
nificant, a trend toward increased re-admissions with high dose IVIG
was noted in this trial [106].
Vasculopathy of sickle cells and coagulation. Virchows triad
describes the three broad categories of factors leading to thrombosis.
In SCD, endothelial damage (caused by direct vascular damage from
ischemic injury and free hemoglobin), stasis (consequence of
decreased blood flow secondary to erythrocyte adhesion and increased
viscosity), and hypercoagulability (due to externalization of phospha-
tidlserine on erythrocytes promoting subsequent thrombin generation,
platelet adhesion and WBC activation) are potential contributors to
thrombus formation. Lastly, platelet elevation and activation in SCD
accelerates the hemostasis cascade.
Eptifibatide, an inhibitor of the platelet aIIbb3 receptor pathway
was studied in a small group of patients with SCD during acute VOC
but showed no measurable benefits [16]. Abciximab (ReoPro, a plate-
let glycoprotein IIb/IIIa receptor antagonist), is currently being stud-
ied as IV infusion in the treatment of acute VOC in SCD patients 5
to 25 years of age. Ticagrelor and Prasugrel are oral platelet aggrega-
tion inhibitors that act via inhibition of the adenosine diphosphate
American Journal of Hematology, Vol. 90, No. 10, October 2015 941
Archer et al.
receptor P2Y12. A phase 2 study tested oral administration of Prasu-
grel (5 mg/day for 30 days, n 5 41) vs. placebo (n 5 21) in patients
with SCD, demonstrating its safety and some changes in markers of
platelet activation [107]. Prasugrel is currently in a phase 3, double-
blind, placebo-controlled study involving up to 220 pediatric patients,
which will test its efficacy in reducing VOC, as a composite point of
either painful crisis or acute chest syndrome. This study will use the
VerifyNowV R P2Y12 test, which quantifies the extent of platelet func-
tion inhibition via the P2Y12 pathway, to titrate Prasugrel to a main-
tenance dose for a treatment period between 9 and 24 months.
Apixaban, a factor Xa inhibitor, is being investigated as a prophy-
lactic agent in a phase 3 study (Table III). The main objective of its
study is to reduce mean daily pain scores in patients greater than 18
years of age with SCD. Rivaroxaban, also a factor Xa inhibitor, is
under evaluation in a phase 2 trial, to examine its effects on vascular
cell adhesion molecule-1 (VCAM-1) and interleukin-6 (IL-6) levels
after 4 weeks of therapy (Table II).
White cells and other cellular and soluble mediators of inflamma-
tion. Several classic studies have shown that the baseline WBC is a
strong predictor of ACS [108], silent strokes [109], and early mortality
in patients with SCD [20]. It is well known that inflammation is a key
component of the pathophysiology of SCD. Several anti-inflammatory
drugs have been and are used in the treatment of acute and chronic
events in SCD, including NSAID and steroids. Hydroxyurea therapy
significantly decreases WBC counts, but how much this change con-
tributes to the beneficial effects of hydroxyurea remains undeter-
mined. Ischemia-reperfusion injury with release of inflammatory
cytokines has also been invoked as a potential mechanism leading to
acute and chronic tissue damage. More recent studies have identified
regulatory steps leading to the inflammatory state of SCD, which are
also potential candidates for therapeutic intervention [110112].
Invariant Natural Killer T (iNKT) cells are currently being investi-
gated as a potential mediator of the inflammatory state of SCD, and
activation of these cells has been demonstrated during VOC [13].
The humanized monoclonal antibody NKTT120 has been shown to
safely deplete iNKT cells in adult sickle cell patients up to a dose of
0.3 mg/kg (ASH 2014, # 2178). iNKT cells are laden with adenosine
receptors. Regadenoson, an adenosine receptor 2A agonist, currently
used to increase coronary blood flow during cardiac nuclear stress
scan, (Lexiscan, Astellas USLLC) is being studied for the acute treat-
ment of VOC, with the intent to down-regulate the inflammatory cas-
cade that is initiated by iNKT activation. In a phase 1 study in
patients with SCD (21 at baseline and 6 during VOC), a 24-h infu-
sion of regadenoson was shown to result in decrease iNKT activation
[13]. A double-blind, placebo controlled, phase 2 study is ongoing to
determine the effects of a 48-h IV infusion of regadenoson on iNKT
cell activation in 96 patients with sickle cell anemia admitted for
acute VOC or mild to moderate ACS (Table II). Other adenosine
receptor ligands are being considered for potential development in
SCD, such as PNQ103 (Advinus Therapeutics, Pune, India), and A2a
PAM (Addex Therapeutics, Geneve Switzerland).
Zileuton (ZYFLO CRV, Chiesi) is a structural analog of hydrox-
R
yurea, which decreases leukotriene production by inhibiting 5-
Lipoxygenase, and is currently marketed for prevention of asthma in
children and adults. Zileuton also induces HbF in erythroid progeni-
tors through a mechanism that involves l-arginine/nitric oxide/cyclic
GMP [113]. A phase 1 study in 11 patients with SCD showed safety
of higher doses than those approved for asthma [12], supporting the
feasibility of a future phase 2 study.
Dimethyl fumarate (Tecfidera, Biogen Idec) currently approved in
the USA for the treatment of relapsing multiple sclerosis, is being
considered for SCD based on both its general anti-inflammatory
properties as well as the ability to activate NRF2 signaling which is
involved in drug-induced HbF expression [114,115].
942 American Journal of Hematology, Vol. 90, No. 10, October 2015
UPDATES IN CLINICAL TRIALS FOR HEMATOLOGICAL DISEASES
The use of the inhaled corticosteroid, Mometasone, in sickle cell
patients with cough or wheeze but no diagnosis of asthma, is also
currently being investigated to assess if it can decrease general pulmo-
nary inflammation. ReveraGen Biopharma (Silver Spring, MD) is cur-
rently developing VBP15, a dissociative steroid, which retains
steroidal efficacy with reduced side effects, for Duchenne Muscular
dystrophy, and has received NIH funding to begin its development
for SCD. This is relevant for SCD because there are concerns about
oral glucocorticoids possibly promoting VOC and accelerating the
development of osteonecrotic complications.
Atorvastatin and Simvastatin, two frequently used lipid lowering
medications, have been considered for SCD. However, Atorvastatin
treatment (1020 mg/day) did not produce measurable improvements
in vasodilatory responses in a small cohort of SCD patients [116]. Sim-
vastatin increased nitric oxide metabolites while decreasing C-reactive
protein (CRP) and interleukin-6 (IL-6) in patients with SCD [117].
Lovaza, an omega-3 fatty acid ethyl ester, is also being investigated for
its role in inflammation in pediatric SCD patients (Table II). In sickle
mice, a diet supplemented with omega-3 fatty acid (fish oil) reduced
several systemic inflammatory biomarkers and improved hypoxia-
reoxygenation associated organ damage [118]. Preclinical data show a
possible role for inhibition of the mitogen-activated protein kinase
ERK1/2 in reducing adhesion and vaso-occlusion (Table IV) [119].
NO, arginine, and hemolysis as a key mediators of vasculopathy.
Nitric oxide is a potent vasodilator produced from the metabolism of
L-arginine by NO synthase, and plays a key role in vascular physiol-
ogy and pathophysiology. In SCD, the transfer of NO from HbS to
the membrane is impaired, resulting in an impaired capability of
red cells to mediate vasodilation [120]. The chronic hemolytic state
of SCD increases plasma Hb values and substantially limits NO bio-
availability, resulting in a NO-deficient state [121]. This NO-
deficient state is believed to be the main determinant for the devel-
opment of pulmonary hypertension [122124], although there have
been different estimates about the true prevalence of this complica-
tion [125], and some spirited academic debates about the hemolysis
hypothesis [125127]. Initial studies showed some promise for
inhaled NO in the treatment of acute VOC [128], but a large
randomized, placebo-controlled, double-blind study, showed no
effect on the time of crisis resolution [129]. Another study on
inhaled NO for the treatment of acute crises in pediatric patients
was terminated early due to slow enrollment, but no data are yet
available about this trial (Table II). Some case reports have sug-
gested a possible therapeutic role for inhaled NO in ACS [130,131].
A case-controlled trial of inhaled NO in adult patients with ACS
has recently been completed in Creteil, France and results have been
submitted for publication. Patients with SCD exhibit a dysfunctional
regulation of arterial tone, which may impair response to variation
in blood flow or shear stress [132,133]. Despite abundant scientific
evidence and strong rationale, studies targeting NO and associated
regulatory pathways have been largely disappointing.
A trial of sildenafil in SCD disease patients with pulmonary hyper-
tension (TRV !2.7 m/s and 6 min walk distance between 150 and
500 m) was terminated early due to serious adverse events in the silde-
nafil arm (mostly increased hospitalization for pain) [134]. A small
study on prevention of recurrent ischemic priapism with sildenafil had
inconclusive results [135]. Similarly, studies assessing endothelin recep-
tor blockade (ASSET-1 and -2, with Bosentan) as a potential therapy
for pulmonary hypertension in SCD were inconclusive due to poor
enrollment [136]. Safety and efficacy of Macitentan (Actelion, Switzer-
land) will be tested in a single center open label trial for precapillary
pulmonary hypertension in SCD at Boston University (Table II).
Low levels of plasma arginine have been demonstrated in steady
state SCD, with further decreases due to acute events and chronic
vascular damage. Human studies have been performed with
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UPDATES IN CLINICAL TRIALS FOR HEMATOLOGICAL DISEASES
arginine, based on the notion that administration of this compound
may improve the relative NO deficiency in SCD, with conflicting
results [137]. Questions have been raised about what should be the
optimal oral arginine dose, suggesting that not enough arginine was
used in a negative NIH-sponsored, phase 2 trial, whose results have
never been formally published. A more recent study compared par-
enteral L-arginine (100 mg/kg tid for 5 days) and placebo adminis-
tration in 38 children with SCD. Although length of stay was not
affected, parenteral opioid use ("50%) and pain scores were signifi-
cantly diminished with L-arginine [138]. It has also been suggested
that administration of arginine and hydroxyurea may be superior to
arginine monotherapy.
Some key mechanisms associated with hemolysis have been identi-
fied as toxic to the body and contributory to the pathophysiology
seen in SCD. Hemolysis leads to the release of free hemoglobin into
the extravascular space, the depletion of nitric oxide, and the creation
of toxic free radicals and hemin [139]. Haptoglobin itself is protective
and by binding to hemoglobin prevents movement of hemoglobin
across endothelial layers. It also limits NO depletion and thus the
release of free radicals and hemin. However, in SCD, haptoglobin is
readily depleted and free hemoglobin must be cleared by heme
oxygenase-1 (HO-1), as the presence of free hemoglobin can cause
multiorgan damage. Preclinical studies show that exogenous haptoglo-
bin decreases the production of HO-1, likely due to a decrease in the
presence of free hemoglobin [140]. Bio Products Laboratory has
received EU Orphan Drug designation for a preparation of haptoglo-
bin to be administered IV to patients with SCD. Preclinical studies in
dogs have shown that this animal model can be used to estimate
clearance of haptoglobin-bound Hb [141].
Vasodilation-increased blood flow-perfusion-oxygenation. MgSO4,
known for his vasodilatory properties, has also been studied in SCD.
However, as detailed above, two randomized clinical trials showed no
effect of IV MgSO4 on the resolution of acute painful crises (ASH
2014 # 88) [17].
A hemoglobin based blood substitute was tested in a clinical trial in
1997, under the assumption that this oxygen carrier could potentially
reverse VOC [142]. While no toxicity was observed in this first study,
subsequent studies for other indications not related to SCD have shown
an association with death and myocardial infarction [143], resulting in
diminished enthusiasm about these compounds as therapeutic agents.
MP4CO was a human hemoglobin, obtained from blood donors,
conjugated with polyethylene glycol (PEG) and saturated with CO. It
was produced with the idea that CO delivery to ischemic areas would
improve perfusion and reduce microvascular stasis and with the
assumption that 5 to 10% HbCO would be nontoxic and could limit
or reverse HbS polymerization as well as producing a vasodilatory
effect. Preclinical studies in sickle mice showed positive changes in
inflammatory parameters and mortality [85], but no data are available
on a phase Ib study funded by Sangart, a company which is no lon-
ger active (Table I). Sanguinate, a pegylated bovine carboxyhemoglo-
bin was tested in a phase 1 trial (Table I). According to a press
release on April 14, 2015 by Prolong Pharmaceuticals (South Plain-
field, NJ; http://www.prolongpharma.com/press-14APR2015) phase 2
trials are planned for VOCs and leg ulcers. A topical sodium nitrate
2% cream was shown to be safe and well tolerated in a phase 1 study
in 18 patients with SCD [14]. Increases in per-wound cutaneous
blood flow and decreased ulcer size were also observed in this trial.
Oxidative damage
Oxidative stress is thought to play a role in the pathophysiology of
SCD, both at the erythrocyte level, as well as in the development of
VOC. Several commonly used supplements are currently being inves-
tigated based on their anti-oxidant properties. Sorghum bicolor
doi:10.1002/ajh.24116
Clinical Trials in Sickle Cell Anemia
extract, Jobelyn is often used as a dietary supplement in Nigeria. Its
antioxidant and anti-inflammatory properties have led to its investi-
gation as a potential SCD agent, with an ongoing trial in Lagos,
Nigeria comparing the effect of daily Jobelyn at different daily doses
(500 mg, 250 mg, and 2 mg) on quality of life (Table II).
It has been hypothesized that N-acetylcysteine (NAC) may help
reduce oxidative damage associated with SCD, based on its capability
of increasing antioxidant systems like the one based on glutathione.
This is currently being tested in a phase 3 trial (Table III).
The amino acid L-glutamine has been shown to increase erythro-
cyte nicotinamide adenine dinucleotide redox potential (NADH). A
randomized, placebo controlled trial evaluated the efficacy and safety
in SCD patients >5 years of age and with a history of at least two
VOC in the previous 12 months. In the 2014 ASH abstract (ASH
2014, # 86) clinical benefit was reported in the treatment arm with
patients receiving L-glutamine having significantly fewer days to first
VOC, number of painful crises, and hospital days. However, Form
10-K filed by Emmaus Life Sciences Inc. with the U.S. Securities and
Exchange Commission, have disclosed significant concerns raised by
the FDA, namely that the primary endpoint of the trial did not reach
statistical significance, that the results were inconsistent among
regions, and that the reduction in painful crises, was not clinically
meaningful and was inconsistent across regions. These concerns
resulted in the recommendation that a second trial be conducted in
patients with higher baseline levels of painful crises [144].
Cell-based therapies
Cell based therapies currently provide the only curative options for
SCD, and they comprise both gene therapies and stem cell transplan-
tation (Table V).
Gene therapies. Several companies have developed groundbreak-
ing gene therapies for SCD that, using a lentiviral vector, insert a
functional human beta or gamma globin gene into a patients own
hematopoietic stem cells. These are then infused into a patient during
an autologous stem cell transplant.
Bluebird Bio is currently assessing the safety and efficacy of the
LentiGlobin BB305 in children and adults with SCD (trials NCT
02140554 and NCT02151526). The use of this vector, which contains
a B-globin gene (BA-T87Q) and produces hemoglobin BA-T87Q has
already been proven successful in patients with Beta-thalassemia
major (ASH 2014, # 549). The therapeutic Hb was designed with a
unique mutation which, while preserving normal O2 carrying proper-
ties, strongly inhibits HbS polymerization. In addition, the lack of a
functional LTR, the use of erythroid specific promoters, and chroma-
tin insulator element make the chance of leukemia unlikely. Prelimi-
nary results have been presented on the first SCD patient treated
under this protocol, showing that after 6 months Hb AT87Q com-
prised 45% of Hb production with associated improvement in trans-
fusion requirements and hemolytic parameters. One additional SCD
patient has been treated under a similar protocol at the NIH.
The University of California, Los Angeles is currently investigating
the use of the recombinant beta globin gene (HBBAS3) in a lentiviral
vector [145]. It too has the T87Q blocking site. In vitro data have
been recently published showing that therapeutic levels can be
achieved for the production of an antisickling Hb using insulated,
self-inactivating and erythroid-specific lentiviral vectors in cultured
CD341 cells from SCD patients [146].
The Childrens Hospital Medical Center at Cincinnati has devel-
oped a novel human gamma-globin gene vector. It is currently
recruiting adult SCD patients for its phase 1 trial. Boston Childrens
Hospital is set to open a phase 1/2 trial that unlike the approaches
highlighted above, involves the insertion of a beta or gamma globin
gene, seeks to knockout BCL11A thus increasing fetal hemoglobin
and bypassing the mutated sickle globin gene.
American Journal of Hematology, Vol. 90, No. 10, October 2015 943
Archer et al. UPDATES IN CLINICAL TRIALS FOR HEMATOLOGICAL DISEASES

TABLE V. Cell-based therapies: applications to sickle cell disease

Company Protocol/agent Mechanism Clintrials. gov Enrollment target Status

Gene Therapy
Blue Bird Bio LentiGlobin BB305 Gene therapy NCT02140554 8 Open
Drug Product HbSS, HbSb0
! 18 years
Blue Bird Bio LentiGlobin BB305 Gene therapy NCT02151526 7 ASH 2014 # 549 &
Drug Product HbSS, HbSb0 4797
Beta-thalassemia
major
5 years ! 35 years
Childrens Hospital Lenti/bAS3-FB lentiviral Gene therapy NCT02247843 6 Open
LA vector Transduction HbSS, HbSb0
to express an anti- ! 18 years
sickling (bAS3) gene
Childrens Hospital Gamma Globin Lentivi- Gene therapy NCT02186418 10 Open
Medical Center, rus Vector-mediated Severe SCD
Cincinnati gene transfer 18 years ! 35 years
Errant Gene Lentiviral vector, TNS Gene therapy N/A N/A Open Phase 1 in
therapeutics 9.55.3 Beta- thalassemia
(NCT01639690)
OrphageniX Targeted Gene Altera- Sickle gene repair N/A N/A Preclinical
tion (TGA)
Sangamo Bioscien- ZFN-mediated gene Sickle gene repair N/A N/A Preclinical
ces (and Biogen correction
Idec?)
Editas Medicine CRISPR-Cas9 & Sickle gene repair- N/A N/A Preclinical
TALENs orincrease HbF
Boston Childrens BCL11A knockdown HbF induction N/A N/A Not yet open
Hospital
HSC Transplant
Cellerant CLT-001 Purify stem cells for N/A N/A Discontinued
Therapeutics HSCT
Gamida Cell Ltd Nicotinamide Expand stem cells, NCT01590628 10 Open
(NiCordVR) HSCT HbSS, HbSb0, HbSC2
years ! 21 years
Morphogenesis SCPF Expand stem cells N/A N/A Discontinued
Assistance Publique Plerixafor Mobilization of stem NCT02212535 5 Not yet open
-Ho^ pitaux de cells HbSS, HbSb0
Paris ! 18 years
University of Louis- Alemtuzumab based Stable Mixed chi- NCT01419704 30 DIscontinued
ville, KY conditioning merism induction hemoglobinopathies,
bone marrow failure
syndromes
# 45 years
Masonic Cancer Stable Mixed chi- NCT00176852 30HbSS, HbSb0, Beta- Open but not
Center, University merism induction thalassemia major recruiting
of Minnesota # 50 years
Hackensack Univer- Alemtuzumab, fludara- Reduced intensity NCT01877837 40 Open
sity Medical bine, and melphalan HSCT HbSS, HbSb0, HbSb1,
Center HbSC
2 years ! 30 years
University of Illinois Alemtuzumab, 300 cGy Non-Myeloablative NCT01499888 15 Open
at Chicago TBI, and sirolimus HSCT HbSS, HbSb0, HbSC
18 years ! 60 years
University of Illinois Alemtuzumab, 300 cGy HLA-Haploidentical NCT02013375 110 Open
at Chicago TBI, post-SCT cyclo- HSCT Severe SCD
phosphamide and 16 years ! 60 years
sirolimus
Sidney Kimmel Fludarabine, cyclo- Partially HLA-Mis- NCT00489281 50 Open
Comprehensive phosphamide, and, matched and Severe SCD
post-SCT sirolimus 2 years ! 70 years
Emory University & Busulfan, fludarabine, Reduced intensity NCT01565616 15 Open (STRIDE)
NHLBI anti-thymocyte Severe SCD
globulin 16 years ! 40 years
University of Texas Low dose irradiation, Non-Myeloablative NCT02038478 50 Open
Southwestern Alemtuzumab and HSCT, Mobilized Severe SCD
Medical Center sirolimus. peripheral stem 18 years ! 45 years
cells
University of Reduced intensity NCT01962415 30 Open
Pittsburgh 2 months ! 35 years
Fred Hutchinson Treosulfan and fludara- HSCT NCT00919503 68 Open
Cancer Research bine, 6 low dose # 54 years
Center irradiation

944 American Journal of Hematology, Vol. 90, No. 10, October 2015 doi:10.1002/ajh.24116
UPDATES IN CLINICAL TRIALS FOR HEMATOLOGICAL DISEASES Clinical Trials in Sickle Cell Anemia

TABLE V. Continued

Company Protocol/agent Mechanism Clintrials. gov Enrollment target Status

New York Medical Hydroxyurea, azathio- Haploidentical T NCT01461837 35 Open

College prine, fludarabine, cell- depleted Severe SCD
busulfan, thiotepa, HSCT 2 years ! 21 years
cyclophosphamide,
and rabbit ATG
NHLBI Low dose irradiation, Non-Myeloablative NCT00977691 192 Open
alemtuzumab, siroli- Haploidentical Sever SCD and Beta-
mus, and Mobilized periph- Thalassemia
cyclophosphamide eral stem cells ! 2 years
NHLBI Low dose radiation Non-Myeloablative NCT02105766 142 HbSS, HbSb0, Open
(300 rads), oral Mobilized periph- 16 years ! 80 years
cyclophosphamide, eral stem cells Up to 142
pentostatin, and
sirolimus
NHLBI Low dose radiation, HSCT NCT00061568 124 Open
Alemtuzumab and Severe SCD
Sirolimus 2 years ! 65 years
Case Comprehen- Fludarabine HSCT NCT02065596 25 subjects Not yet open
sive Cancer HbSS, HbSb0, HbSb1,
Center HbSC
! 18 years
Vanderbilt-Ingram Thymoglobulin, Non-myeloablative NCT01850108 10 Open
Cancer Center fludarabine partially HLA
cyclophosphamide matched and fully Severe SCD
sirolimus, 200 cGy HLA matched 2 years ! 70 years
TBI

Preclinical evidence shows promise for the use of zinc-finger nucle-
ases (ZFNs) in site-specific correction of the HbS mutation in mouse
and human sickle CD341 precursors [147]. However, new powerful
genome editing techniques like CRISPR are likely to revolutionize
gene therapy for hemoglobinopathies [148].
Several companies, including Errant Gene therapeutics and Editas
Medicine are currently working with CRISPR-Cas9 systems to
develop strategies to modify the mutated sickle cell gene, while San-
gamo Biosciences is attempting to develop Zinc Finger Nuclease
(ZFN) mediated gene correction. OrphageniX has tried a different
approach and is developing therapies based on targeted gene altera-
tion (TGA) which involves the delivery of strategically mismatched
oligonucleotides to the nucleus of the cell, feeding off of the bodys
natural DNA repair processes.
Stem cell transplantation. Hematopoietic stem cell transplant
(HSCT) is currently the only approved cure for SCD. In centers with
considerable experience with this approach, and when patients are
treated before transplant with hydroxyurea, or if the transplant took
place after January 2000, event-free survival rates of 97.4% and 95.3%,
respectively, have been reported [149,150]. Overall survival is similar
for either bone marrow transplant or cord blood transplant [151].
However, the potential associated morbidity and mortality often
make HSCT a less considered treatment option [7]. For many providers,
the difficulty in recommending transplant lies in our inability to predict
clinical severity before the advent of significant morbidity, which in
some cases can greatly affect transplant outcomes. Guidelines recom-
mending stem cell transplant as a therapy for severe disease as opposed
to a cure for all patients with the mutation, has also led to underuse.
In reality, overall survival and disease free survival in select popu-
lations has been shown to be equal to that of patients treated sympto-
matically without transplant [152]. Therefore, experts recommend
that symptomatic patients with an HLA-matched sibling undergo
transplantation preferably when they are pre-school age [6]. However,
a major problem within the sickle cell community is the lack of
healthy, HLA-matched siblings. In those without a sibling match,
transplantation is only recommended in the setting of a controlled
clinical trial.
At present, there are several ongoing clinical trials that are studying
the success of diverse myeloablative, nonmyeloablative, and reduced
intensity regimens in both matched sibling and unrelated sibling donor
transplants. A reduced intensity regimen is meant to decrease morbid-
ity and mortality associated with transplant, especially in those with
preexisting co-morbidities. It also increases the likelihood of mixed
donor chimerism, which, if high enough in SCD, can result in predomi-
nance of donor cells in the circulation [153]. Mixed donor chimerism
and the addition of antibodies against mature lymphocytes, namely
anti-thymocyte globulin or alemtuzumab, provide additional graft ver-
sus host disease prophylaxis. Case Comprehensive Cancer Center is
planning a trial that uses solely fludarabine for conditioning
(NCT0206559). A preliminary study has provided encouraging evi-
dence that fludarabine can be used to reduce exposure to busulfan and
cyclophosphamide in children with SCD undergoing HLA-matched
HSCT [154].
A nonmyeloablative regimen composed of low dose radiation,
alemtuzumab, and sirolimus is also being studied in older patients by
University of Texas Southwestern Medical Center, University of Illi-
nois at Chicago (UIC), and the National Heart Lung and Blood Insti-
tute (NHLBI). UT Southwestern is using peripheral stem cells while
NHLBI and UIC are using bone marrow as their stem cell source. In
another study, NHLBI has proposed using the same conditioning reg-
imen backbone with additional pentostatin and oral cyclophospha-
mide in patients considered at high risk for transplant failure (i.e.
female recipients of male donors those with preexisting allo-antibod-
ies and those receiving peripheral stem cells).
As not all patients have a fully matched HLA sibling for trans-
plant or an unrelated match, haploidentical transplantation has
been proposed as an alternative. New York Medical College,
Vanderbuilt-Ingram Cancer Center, UIC, and NHLBI all have
ongoing trials.
Treatment of pain in sickle cell disease
Ballas et al. described the hallmark of SCD as acute continuous
pain as it is the most common reason for inpatient hospitalization

doi:10.1002/ajh.24116 American Journal of Hematology, Vol. 90, No. 10, October 2015 945
Archer et al. UPDATES IN CLINICAL TRIALS FOR HEMATOLOGICAL DISEASES

TABLE VI. Currently planned, ongoing, or recently completed clinical trials on treatment of pain in sickle cell disease

Company Drug Design Indication Phase Enrollment Endpoints Clintrials.gov Status

Duke University Morphine Randomized Acute VOC 4 77 Pain scores NCT02222246 Not yet open
(NHLBI) Sulfate or Patient-specific treatment HbSS,
Hydromorphone vs. standard HbSb0, HbSb1,
dosing HbSC
!21 years
Childrens Morphine Randomized Acute VOC 3 40 Pain control NCT01380197 Open but not
Healthcare or Nubain double blind treatment HbSS, acute chest recruiting;
of Atlanta HbSb0, HbSb1, syndrome (COMPARE)
HbSC
6 years >
19 years
University Music therapy vs. Randomized Prophylaxis 120 Pain intensity, NCT02270060 Open
Hospital Music Listening HbSS, relief and mood
Case vs. no intervention HbSb0, HbSb1,
Medical HbSC
Center !18 years
Centre Leon Lidocaine 5% Open-label Acute VOC 2 39 Pain scores NCT01314300 Completed
Berard plaster treatment 6 years >
(versatic 5%) 21 years
St. Jude Gabapentin vs. Randomized Acute VOC 2 190 Pain scales NCT01954927 Open
Childrens placebo Double blind treatment 1 years >
Research 20 years
Hospital
University of Vaporized Randomized Chronic pain 1-2 35 Pain scores NCT01771731 Open
California, cannabis (4.7% Crossover treatment HbSS,
San Francisco THC/5.1% CBD) Double blind HbSb0, HbSb1,
(NHLBI) vs. placebo HbSC
!18 years

Montefiore Intranasal Randomized Acute VOC 4 200 Pain scores NCT01482091 Open
Medical fentanyl citrate Double blind treatment HbSS,
Center HbSb0, HbSb1,
HbSC
3 years >
21 years
Columbia Nitrous Non-randomized, Acute VOC 2 12 Pain scores NCT01891812 Open
University oxide 50% open label treatment HbSS,
HbSb0, HbSb1,
HbSC
8 years > 18
years
Nationwide Warmed Randomized, Acute VOC 80 Rate of hospital NCT02316366 Completed
Childrens saline open label treatment HbSS, admission
Hospital, HbSb0, HbSb1,
Columbus, OH HbSC
4 years > 21
years
Brooklyn IV Ketamine Double blind, Acute VOC 2/3 106 Pain Scores and NCT02417298 Open
Hospital placebo- treatment HbSS, admission rates
Center controlled HbSb0, HbSb1,
HbSC
!18 years
Makerere Low-dose Double blind Acute VOC 4 240 Pain scores NCT02434939 Open
University, Ketamine vs treatment HbSS,
Kampala morphine HbSb0, HbSb1,
Uganda HbSC
7 years > 18
years

and treatment in the emergency department (Table VI) [155]. At
present the mainstay of treatment for pain in VOC is opioids. Several
interventional trials are ongoing to assess alternative modalities to
decrease either pain scores during and between VOC. Nationwide
Childrens Hospital recently completed a trial investigating whether
warmed saline given to children who present with VOC may decrease
hospital admission, IV analgesic usage, and pain scores. The safety
and efficacy of lidocaine 5% plasters in pediatric patients with SCD
experiencing neuropathic pain is being investigated at the Centre
L!eon B!erard (Lyon, France). Results are not yet available for either of
these trials. Still recruiting are trials comparing different opioids such
as morphine, hydromorphone, gabapentin, and intranasal fentanyl to
those investigating the benefits of music therapy, cannabis, inhaled
steroids and nitrous oxide. All studies are welcomed by the SCD
community as opioids alone only address one component of the
pathophysiology behind VOC i.e. nociception, but fail to address
both vaso-occlusion and inflammation. In addition, trials should
focus on early treatment during the prodromal stage of VOC as well

946 American Journal of Hematology, Vol. 90, No. 10, October 2015 doi:10.1002/ajh.24116
UPDATES IN CLINICAL TRIALS FOR HEMATOLOGICAL DISEASES Clinical Trials in Sickle Cell Anemia

TABLE VII. Studies on pharmacological treatment of iron overload in sickle cell disease

Company Drug Design Criteria Phase Enrollment Endpoints Clintrials.gov Status

ApoPharma Deferiprone Randomized !6 years; 4 300 Liver iron NCT02041299 Open

(Ferriprox) vs open label Baseline LIC > concentration UCTR2013-002181- (FIRST)
deferoxamine 7 mg/g dw 39-GB
(Desferal)
Consorzio per Deferiprone Randomized 1 month< 3 344 Ferritin and NCT01825512 Not yet open
Valutazioni (Ferriprox) vs open label 18 years cardiac iron
Biologiche e Deferasirox concentration
Farmacologiche (Exjade)
(EC)
Shire plc Deferitazole Non-randomized Variable 1 and N/A Liver iron NCT01363908 All trials
(previously (SPD602 or open label 2 concentration NCT01604941 discontinued
Ferrokin SSP-004184) (NCT01927913 NCT01671111 July 2014
Biosciences) randomized Withdrawn:
open label) NCT02065401
NCT01927913

as on how to minimize the hyperalgesia and fear that often accompa-
nies recurrent painful episodes.
Iron overload in sickle cell disease
Chronic transfusion therapy is still the main therapy for primary
and secondary stroke prophylaxis (Table VII). Transfusion therapy is
also widely used for acute chest syndrome. Thus, transfusional iron
overload is a significant problem for patients with severe SCD. Chela-
tion is typically started 2 to 3 years after chronic transfusion therapy is
initiated or once ferritin exceeds 1,000 ng/mL. Unfortunately, current
therapies are often not well tolerated, especially in the pediatric setting.
Current therapies include oral deferasirox, subcutaneous or IV defer-
oxamine, and oral deferasirox in combination with deferiprone [156].
Previous studies have demonstrated the safety and efficacy of defera-
sirox compared with deferoxamine in patients with iron overload and
SCD [157]. Apopharma is currently recruiting patients to assess the
safety and efficacy of deferiprone compared with deferoxamine. The
primary endpoint is change in liver iron concentration. A similar
study, yet to open, will take place in Italy. It will include patients as
young as 1 month of age and will assess successful chelation based on
ferritin and cardiac MRI T2*. Shire recently terminated all clinical tri-
als for deferitazole (SHD602) in the treatment of iron overload.
Additional therapeutic modalities
Orthopedic complications such as osteonecrosis of femur and
humeral heads represent an important clinical feature of SCD
[158,159]. In recent years, the outcome for procedures like total hip
arthroplasty has improved substantially and is not different from
patients with osteonecrosis not due to SCD [160].
Renal disease occurs early in SCD and may ultimately lead to
chronic renal failure. The pathophysiology of the SCD nephropathy is
complex, and the clinical manifestations are variable [161,162]. Hyper-
filtration is a common finding in children with SCD, but hypofiltration
can also be present in a smaller subset [163]. Hydroxyurea therapy can
play a significant role in retarding the progression of renal disease in
SCD [164]. The angiotensin II receptor losartan is currently being stud-
ied for the prevention of sickle nephropathy in children and young
adults with SCD (Table II, CT01479439 and NCT02373241).
Impaired rheology plays a key role in the pathogenesis of the com-
plications of HbSC disease, and is believe to result in the 70% inci-
dence of retinopathy and 29% incidence of sensorineural ontological
disease, substantially higher than in non-SCD populations [165,166].
Limited evidence suggests a beneficial effect of phlebotomy in pre-
venting recurrence of acute complications [165].
Despite overwhelming evidence for the benefit of vaccination in
children with SCD, pneumococcal vaccination rates are still subopti-
mal in the US and the incidence of invasive pneumococcal disease is
still greater than in the general population [167,168]. Similarly disap-
pointing data have been reported for adherence to penicillin prophy-
laxis and for influenza vaccination [169].
Relevant endpoints for SCD clinical trials
The clinical trial which resulted in the approval of hydroxyurea for
adults with SCD remains so far the only prototype for current trials
aiming at pharmacologic reductions of clinical complications of SCD
[27]. To the best of our knowledge, the FDA has not allowed phase 3
trials based on biomarkers or other disease indicators outside of
transfusion and acute events (acute chest and/or VOCs resulting in
patient admission). Alternative assessment of pain and disease sever-
ity (pain diaries) have been proposed but not fully validated. Valida-
tion of novel endpoints for SCD, especially related to pain, remains
an important target for future studies.
! Methods
Information on clinical trials was obtained from several sources. (a) Clinical-
Trials.gov (https://clinicaltrials.gov) was searched for studies including the term
sickle; studies were not included if the status of the study was listed as completed
(with a completion date before 2013), terminated, unknown, or withdrawn. Obser-
vation trials were not included. (b) The WHO International Clinical Trials registry
platform http://apps.who.int/trialsearch/ and the European registry (https://www.
clinicaltrialsregister.eu/) were searched for additional studies not listed in the Clini-
calTrials.gov database. Studies were then organized based on clinical phase (1, 2, 3),
with separate tables for studies on cell-based therapies, pain treatment and iron
overload. Information for preclinical studies was obtained from literature searches
and review of abstracts presented at the 2013, 2014 American Society of Hematol-
ogy and 2014 and 2015 European Hematology Association meetings.
! Conclusions
A substantial number of clinical trials are ongoing or planned to test
new treatments for SCD. The majority of these trials is supported by
private companies, which represents a profound and positive change
compared with the prior decade. This is most likely the result of the sig-
nificant investments in fundamental research on SCD pathophysiology
that NIH supported in the past 30 years and the realization for many
biotechnology and pharmaceutical companies that the orphan status of
SCD provides unique advantages for drug development and marketing.

doi:10.1002/ajh.24116 American Journal of Hematology, Vol. 90, No. 10, October 2015 947
Archer et al.
We hope that these studies will result in the approval of new treatment
for SCD, either as a single agent or in combination with hydroxyurea.
Treatment or prevention of VOC in SCD is the central aim of new
therapies. They will permit a better quality of life and facilitate more nor-
mal educational or occupational activities and ultimately translate into a
significantly longer life expectancy. The development of these novel
therapies poses a significant challenge for the so-called curative thera-
peutic approaches, which will have to demonstrate substantial advan-
tages in cost and short-term and long-term toxicities to be considered as
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